Form library
Claims
Network advantage for behavioral health claims
Generally, in-network claims will be submitted by your network provider. However, if you use an out-of-network provider, you’ll need to submit the claim yourself online or through mail.
Filing out-of-network claims online
You’ll be asked to sign in, if you haven’t already.
Filing out-of-network claims by mail
For corrected claims, adding supporting documents and other instances, you’ll need to submit a claim by mail.
Mail your form to: Claims processing, PO Box 30755, Salt Lake City, UT 84130-0755
Requesting support and services
Excuse for Absence
At times, employees may find that their mental health is impairing their ability to work. The Excuse for Absence process allows an employee to request that a licensed therapist assess their current situation and determine whether the employee may be temporarily excused from work. Engaging in this process does NOT guarantee that the clinician will recommend a SEAP Excuse for Absence.
An EFA does not replace or supersede the employer’s administration of its leave policies & procedures. It does not determine whether or not the employee will be paid while they are away.
Questions about workplace polices should be directed to the/your SEAP Coordinator.
- To be eligible, the employee must first call into the State Employee Assistance Program (SEAP) (800.692.7459) to discuss care and next steps. SEAP is available 24/7.
- SEAP can assist employees in identifying an in-network, licensed provider to complete the assessment and offer their recommendations. The employee is required to be in ongoing care with a licensed clinician throughout the duration of time off.
- The employee is expected to follow workplace call-out procedures for the duration of the EFA.
- When ready to return, SEAP must receive advance notification from the clinician recommending a specific Return to Work date.
Please provide this document Opens in a new window to the treating clinician. The PEBTF Employee will complete the release of information and the rest of the form must be filled out by the treating clinician. Then both forms will be sent, by the clinician, to the SEAP Management Consultants with/at Optum via email: SEAP@optum.com or by fax at 866.340.5325. No information should be sent to the workplace.
For any questions, please call SEAP 24/7 at 800.692.7459
Note this is only for employees with PEBTF – this should not be used for any other employer/company nor does this apply to family members of PEBTF employees.
Managing your health
Confidential exchange of information
Use this form to allow your behavioral health provider to contact your medical doctor. This is important because you may receive medication from both providers, and some medicines can interact negatively. Your doctors need to know all the medicines that you’re taking and any medical issues you have to ensure you receive the best and safest treatment.
Managing your health care information
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you the right to access, amend, share and monitor your health info. The forms on the next page will help you manage that info.
Release of information
This form gives permission to share your personal info with people you choose, like family, doctors and insurance companies. You’ll need to include all necessary documents and electronically sign the form. If you have an Illinois address, you can’t use this electronic form due to state law.
Wellness assessment
Complete this brief pre-visit questionnaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs.
EAP Wellness Assessment (Adult)
Complete this brief pre-visit questionnaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs.
Appointment of representative
A commercial member (or “patient”) may use this form to designate an authorized representative to act on their behalf regarding a grievance, payment appeal or denial of service appeal.
Requesting support services
Childcare
Let us look for anything from all- day childcare to after-school programs.
Eldercare
Whether they need a little help or full-time care, let us assist in finding care for the elder in your life.
Convenience services
We can help you find resources for anything from hobbies, recreation, home repair, travel, and more.
Parenting support groups, classes and more
We can help you find prenatal classes, postpartum support and parenting classes for any parent and parenting situation.
Educational opportunities
We can help find education resources for pre-school through high school and beyond (college, certification programs, distance learning, etc.)